EF 5-10% and spinal?

[apma77]

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Pt came in with inguinal hematoma (urgent case), EF 5-10% non ischemic cardiomypoathy; bullshi# cardiology "clearance" indicates "pt cleared for spinal only"
what a BS setup!!
i call the cardiologist prior to proceeding ; NO answer after multiple pages
also in cardiac eval says "pt needs AICD evaluation soon"

now why the hell would i do a spinal , give sympathectomy possibly and burn my bridges???
putting this guy under GA is also dangerous...

so what did i do?? I did it under MAC with 2 mg versed and REMIfentanil infusion. no problems...pt did well.. i couldnt believe i got away with it...

anyone here would do a spinal on this guy?? (maybe an epidural but a spinal??)

 

[Planktonmd]

Pt came in with inguinal hematoma (urgent case), EF 5-10% non ischemic cardiomypoathy; bullshi# cardiology "clearance" indicates "pt cleared for spinal only"
what a BS setup!!
i call the cardiologist prior to proceeding ; NO answer after multiple pages
also in cardiac eval says "pt needs AICD evaluation soon"

now why the hell would i do a spinal , give sympathectomy possibly and burn my bridges???
putting this guy under GA is also dangerous...

so what did i do?? I did it under MAC with 2 mg versed and REMIfentanil infusion. no problems...pt did well.. i couldnt believe i got away with it...

anyone here would do a spinal on this guy?? (maybe an epidural but a spinal??)

Low ejection fraction is not a contraindication to spinal anesthesia.

 

[bubalus]

Depends on the nature of his failure and his filling pressures. Sometimes these folks with poor EF do better when they are afterload reduced. I'm sure I'll get crap for suggesting it, but a spinal might not necessarily be a bad idea in him. Some of the best anesthesiologists I know would consider it after doing an echo, depending on their findings. A lot of it would depend on his filling pressures. Show me his echo and I'll give you an answer. Now I wouldn't give that answer on the oral boards. In fact, I'd say to do it under local.

In a similar vein, most people would say a spinal is contraindicated in AS. Again, I wouldn't give that answer on the oral boards, but in my mind, it's not necessarily contraindicated. It all depends on their filling pressures. If you've got AS with normal filling pressures, a spinal likely won't cause much in the way of a problem.

I know I'm being something of a heretic. Go ahead and bring the stake, wood, and matches. I'm ready.

 

[militarymd]

I put these patients under GA

 

[apma77]

if MAC didnt work i was going to tube the patient; to me ...if you get a high spinal you are FU#$%D ; then good luck chasing the hemodynamics

 

[militarymd]

if MAC didnt work i was going to tube the patient; to me ...if you get a high spinal you are FU#$%D ; then good luck chasing the hemodynamics

what? you guys dont' have epinephrine stocked in the carts where you work?

I recommend changing jobs/residencies.

 

[urge]

Pt came in with inguinal hematoma (urgent case), EF 5-10% non ischemic cardiomypoathy; bullshi# cardiology "clearance" indicates "pt cleared for spinal only"

What was the cause of the hematoma. A cath?

I wouldn't have done a spinal either. I think they are more dangerous than GA. BP will drop immediately and be a problem for 2 hrs or more. Then you'll be chasing it with neo/epi... and give a bunch of volume along the way. I would have placed an LMA or local with sedation like you did.

 

[bubalus]

Problem with neo is that he's got a sucky heart and you're going to make it work harder by increasing the SVR. At least with epi you preserve or increase your stroke volume. Lots of fluid may be a bad choice if he's got high filling pressures. You could easily put him into pulmonary edema or worsen his heart failure. Like I said before, it all depends on the echo.

 

[militarymd]

Problem with neo is that he's got a sucky heart and you're going to make it work harder by increasing the SVR. At least with epi you preserve or increase your stroke volume. Lots of fluid may be a bad choice if he's got high filling pressures. You could easily put him into pulmonary edema or worsen his heart failure. Like I said before, it all depends on the echo.

You've GOT to be KIDDING.

 

[Noyac]

Problem with neo is that he's got a sucky heart and you're going to make it work harder by increasing the SVR. At least with epi you preserve or increase your stroke volume. Lots of fluid may be a bad choice if he's got high filling pressures. You could easily put him into pulmonary edema or worsen his heart failure. Like I said before, it all depends on the echo.

Let me clarify what Mil is getting at when he says "You've GOT to be KIDDING".
What does a spinal cause? VASODILATION
What does neo cause? VASOCONSTRICTION
You see where were I'm going with this?

 

[Noyac]

First of all I highly doubt that this guy EF is really 5-10%. secondly, it doesn't really matter how you anesthetize him as long as you know what you are doing and the physiology.
Personally, I put an LMA in these guys.

But a spinal can work as well. Remember our talk about unilateral spinals? How about a isobaric spinal. These pts don't drop their BP as dramatically as the OB pts do.

So can some sedation with local depending on the severity of the hematoma, Ketamine is awesome here.

 

[Arch Guillotti]

I have put an LMA in a couple of these gomers before but I didn't really care for it that much - seemed like they barely tolerated any anesthesia at all (duh). That is fine w/me but each time they jumped when stimulated surgically b/c the gas was so light. Surgeons were not too happy.

 

[Noyac]

I have put an LMA in a couple of these gomers before but I didn't really care for it that much - seemed like they barely tolerated any anesthesia at all (duh). That is fine w/me but each time they jumped when stimulated surgically b/c the gas was so light. Surgeons were not too happy.

Dude, deepen the anesthetic like you would for anyone else. Support BP as necessary.

These gomers are fragile but you'd be surprised what they can take when your vigilant. I'm not saying that these are easy cases but THEY ARE.

I'd rather do these cases then a carotid endarterectomy with a surgeon that can't seem to localize the carotid bulb well enough any day.

 

[SleepIsGood]

Am I missing something?

The OP wants to avoid General Anesthesia. Last time I checked LMA is considered General Anesthesia....essentially same thing has putting a ETT minus the mx relaxant and reversal agents....


Dont get me wrong I love LMA cases (you can be down with a case and pull them out quick)....

However, in terms of hemodynamics does it really matter that you have a LMA vs ETT? You still have gases on board (which are myocardial depressants).

Which brings me to another point that someone brought up. When you have a weak heart (EF 5%)...you are giving a myocardial depressant..then like someone mentioned when the pressure goes down you are giving phenylephrine (increases SVR). Now the weak, myocardially depressed heart has to pump against a high SVR......

 

[militarymd]

Am I missing something?

The OP wants to avoid General Anesthesia. Last time I checked LMA is considered General Anesthesia....essentially same thing has putting a ETT minus the mx relaxant and reversal agents....


Dont get me wrong I love LMA cases (you can be down with a case and pull them out quick)....

However, in terms of hemodynamics does it really matter that you have a LMA vs ETT? You still have gases on board (which are myocardial depressants).

Which brings me to another point that someone brought up. When you have a weak heart (EF 5%)...you are giving a myocardial depressant..then like someone mentioned when the pressure goes down you are giving phenylephrine (increases SVR). Now the weak, myocardially depressed heart has to pump against a high SVR......

one more time.....YOU"VE GOT TO BE kidding......

 

[Noyac]

Am I missing something?

The OP wants to avoid General Anesthesia. Last time I checked LMA is considered General Anesthesia....essentially same thing has putting a ETT minus the mx relaxant and reversal agents....


Dont get me wrong I love LMA cases (you can be down with a case and pull them out quick)....

However, in terms of hemodynamics does it really matter that you have a LMA vs ETT? You still have gases on board (which are myocardial depressants).

Which brings me to another point that someone brought up. When you have a weak heart (EF 5%)...you are giving a myocardial depressant..then like someone mentioned when the pressure goes down you are giving phenylephrine (increases SVR). Now the weak, myocardially depressed heart has to pump against a high SVR......

Yes, you are missing something. LMA is a general. But an LMA general can be very different from a ETT general. No, an LMA is not the same as a ETT general anesthetic.
No it doesn't matter if you have a ETT or an LMA as far as hemodynamics, if you are not vigilant. For instance, I have given pts like this one 2-6 cc propofol and then slipped an LMA in then gently maintained a general anesthetic without any consequences. Can you do that with an ETT? I can't.
But if you are vigilant, the difference is great. the myocardial effect of gases is not all or none.


As far as the myocardial depressant and neo debate goes. You are reversing the vasodilation. If the heart can keep up then your golden. If not, then you give the heart a boost, epi. i know it sounds like I am saying that this is the case every time. Quite the contrary, but you use what you have to accomplish the goal. If this guy is walking then his EF is not 5%. He can tolerate a very gentle general anesthetic.

 

[SleepIsGood]

Yes, you are missing something. LMA is a general. But an LMA general can be very different from a ETT general. No, an LMA is not the same as a ETT general anesthetic.
No it doesn't matter if you have a ETT or an LMA as far as hemodynamics, if you are not vigilant. For instance, I have given pts like this one 2-6 cc propofol and then slipped an LMA in then gently maintained a general anesthetic without any consequences. Can you do that with an ETT? I can't.
But if you are vigilant, the difference is great. the myocardial effect of gases is not all or none.


As far as the myocardial depressant and neo debate goes. You are reversing the vasodilation. If the heart can keep up then your golden. If not, then you give the heart a boost, epi. i know it sounds like I am saying that this is the case every time. Quite the contrary, but you use what you have to accomplish the goal. If this guy is walking then his EF is not 5%. He can tolerate a very gentle general anesthetic.

Hey Noy

I hear what you are saying. You do have more practical experience.

In training we are still advised that a general anesthetic is a general anesthetic. Of course I've kept people on very low MACs with a ETT tube....of course this is on Trauma pts (i'd keep this at 0.2-0.4 of sevo..titrate in midazolam for amnesia)...

I dont think you could keep someone on 0.2 of Sevo on an LMA. Plus if you keep them that light on an LMA we are taught that you can run the risk of for example larynospasm.

Good discussion though. MilMD...could you expand on your answer?

To me a 'light general' is sort of like a surgeon who recommends 'light anesthesia'. Although they are requesting MAC they really want the pt 'out'...ie enough propofol/fent to call it a general anesthetic. Remember, with conscious sedation/MAC you are 'supposed' to still have meaningful contact with the pt....this almost never happens I realize.

 

[Arch Guillotti]

Yes, you are missing something. LMA is a general. But an LMA general can be very different from a ETT general. No, an LMA is not the same as a ETT general anesthetic.
No it doesn't matter if you have a ETT or an LMA as far as hemodynamics, if you are not vigilant. For instance, I have given pts like this one 2-6 cc propofol and then slipped an LMA in then gently maintained a general anesthetic without any consequences. Can you do that with an ETT? I can't.
But if you are vigilant, the difference is great. the myocardial effect of gases is not all or none.


As far as the myocardial depressant and neo debate goes. You are reversing the vasodilation. If the heart can keep up then your golden. If not, then you give the heart a boost, epi. i know it sounds like I am saying that this is the case every time. Quite the contrary, but you use what you have to accomplish the goal. If this guy is walking then his EF is not 5%. He can tolerate a very gentle general anesthetic.

Agree, at the start of residency would never have considered these LMA cases. Partly because of the way we are taught. For some dumb reason I clealry remember early in my CA-1 year discussing induction plans for a pt. w/a very weak EF. I asked the attending (who noone really likes) if he would put in an arterial line pre-induction (remember I was a noob). He looked at me like I was nuts and said "**** yeah man!" (trying to be all cool about things when he was really being a ****).

Then my CA-3 year I did a few of these cases w/some younger and wiser attendings who would do a GENTLE propofol induction and SLIP the LMA in. So I saw that it could be done w/out aline and ETT. Still had to give epi a couple of times to keep the bp up so an appropriate level of anesthesia could be maintained (and the pt. still jumped unfortunately).

Anyways the original case is emergent so the guy probably isn't NPO so an LMA is out anyways.

 

[militarymd]

what noy said...

this "theoretical" myocardial failure in a non CPB / non bloodletting trauma septic case....is just so rare that what are we even talking about it.

 

[Noyac]

H
In training we are still advised that a general anesthetic is a general anesthetic. Of course I've kept people on very low MACs with a ETT tube....of course this is on Trauma pts (i'd keep this at 0.2-0.4 of sevo..titrate in midazolam for amnesia)...

I dont think you could keep someone on 0.2 of Sevo on an LMA. Plus if you keep them that light on an LMA we are taught that you can run the risk of for example larynospasm.

Well 0.2 is pretty low. Hell, I would probably still be talking to you if you had me at 0.4-0.6 sevo (thanks Grey Goose). My partner said I woke up long b/4 he ever expected.

I have NEVER seen laryngospasm with an LMA in place and adequate gas onboard. Adequate is obviously relative. But you know how to deal with laryngospam, don't you?

These gomers do pretty well however, with very low conc of gas.

 

[SleepIsGood]

Well 0.2 is pretty low. Hell, I would probably still be talking to you if you had me at 0.4-0.6 sevo (thanks Grey Goose). My partner said I woke up long b/4 he ever expected.

I have NEVER seen laryngospasm with an LMA in place and adequate gas onboard. Adequate is obviously relative. But you know how to deal with laryngospam, don't you?

These gomers do pretty well however, with very low conc of gas.

yah...laryngospasm is easy to fix...put again you run the risk when you are treating that to give propofol (which again will cause dec in BP...so you are chasing your tail)...or giving sux (so now, might as well have put in a tube since you have to ventilate now and theoretically in an 'emergent' case they could be 'full stomach').

I suppose anything is possible. You guys in PP probably do things which in residency we are taught are completely wrong. Whatever is safe I suppose.

To the OP...I think in our world in residency...we would have done what you did....MAC and asking the sx for lots of local infiltration

 

[Noyac]

yah...laryngospasm is easy to fix...put again you run the risk when you are treating that to give propofol (which again will cause dec in BP...so you are chasing your tail)...or giving sux (so now, might as well have put in a tube since you have to ventilate now and theoretically in an 'emergent' case they could be 'full stomach').

I suppose anything is possible. You guys in PP probably do things which in residency we are taught are completely wrong. Whatever is safe I suppose.

To the OP...I think in our world in residency...we would have done what you did....MAC and asking the sx for lots of local infiltration

You guys keep saying things are different in PP but think about it. Do what is practical. Do what makes sense. I'm not telling you to do something risky or unsafe. I'm telling you how to do a case like this without getting into a big mess. One thing we do very well in anesthesia is manage risk. i believe we do this better than any other field of medicine out there. ****, it is the bread and butter of our career.
So stop telling me we do things differently in PP. Ask your attendings, WHY? don't just do what they tell you. Make sure it makes sense to you.

You are telling me you are afraid to put an LMA in someone like this b/c of laryngospasm? Give me a break. Laryngospasm is easy to fix, hypotension is someone with **** for cardiac fxn is not always easy to fix. I'll take laryngospasm any day. 20mg sux will fix it no problem and they don't need to be intubated. Full stomach, oh well. I guess if he ate a cheeseburger on the way to the OR I'd be worried.

Ask why, what we preach here is considered wrong by your attendings. If you feel we are leading you in the wrong direction, ask your attending (preferably one you respect). If the answer makes sense and you believe it is better than what I or some of our PP crew here states then fine, go with it.

PS: you will see the light soon enough.

 

[apma77]

Analgesic based sedation with remi and a touch (25mcg/kg/min) propofol seems to do wonders with these gomers even for high stimulation cases.
Call me a woos but i wouldnt burn my bridges with a spinal then chase it with epi..just not worth it in my opinion.

Ive been trying remi alot lately and its great for stable hemodynamics and "stuns" the patient fast like ketamine without the hypertension and tachycardia

 

[9french]

One other thing to take into consideration is that he has a high probability of being on a anticoagulant. These guys with severe CHF with EF's less than 20 are often placed on long-term coumadin. Also if the inguinal hematoma is from a recent cath, he may have been loaded with some sort of anti-platelet therapy. For this reason alone, I would avoid a spinal.

 

[Noyac]

Call me a woos but i wouldnt burn my bridges with a spinal then chase it with epi..just not worth it in my opinion.

You are not planning on using the epi. It was a discussion about how to deal with the adverse consequences should they occur, which is very rare.

 

[Mman]

What's wrong with an isobaric spinal? Most patients barely have any drop in BP with it and since they are working in the groin, even a modest dose will give you perfect coverage in the T12-L3 dermatomes they will be working in (no need to cover sacral roots). This is all assuming he isn't anticoagulated to the point of contraindicating a spinal. As an aside, I wonder if the cardiologist even puts one second of thought into anticoagulation when issuing the BS statement that they are cleared for spinal only. Maybe the cardiologist should place the spinal that he is clearing the patient for.


As for phenylephrine in a low EF patient after spinal. It's not exactly a bad idea if used judiciously. Most of the BP elevation after a dose of phenylephrine is from venoconstriction leading to increased preload for the LV. It isn't simply an arteriolar constrictor that increases SVR. If it was, you'd never use it because you'd always be reducing forward flow and perfusion. Watch what happens to cardiac output when you give it to someone with a PA catheter in place, the CO goes up along with the BP. Now when you get down to someone with a really crappy LV, you have to be careful because you are increasing the afterload to some extent, but the increase in preload will usually outweigh the elevated afterload when it comes to the cardiac output.



If I was doing this case it'd either be an isobaric spinal or under MAC with the surgeon infiltrating plenty of local. If I did GA, I'd want the surgeon to still use a decent amount of local so I could get by with minimal gas concentrations.

 

[Planktonmd]

There is no right or wrong answer here.
Like everything we do there are many ways to do it and all of them are valid as long as you know what you are doing.
It is possible to do a spinal without major hemodynamic compromise in this patient, for example you can do a low dose hyperbaric Bupivacaine spinal in the lateral position with the surgical side down and wait 5-10 minutes to get a nice unilateral block, or you can do a CSE or place an intrathecal Catheter, you even might be able to do this case under lumbar plexus block or straight epidural, or you can just insert an LMA and get it over with.🙂
You can do anything as long as you know what you are doing.

 

[Intubate]

What's wrong with an isobaric spinal? Most patients barely have any drop in BP with it and since they are working in the groin, even a modest dose will give you perfect coverage in the T12-L3 dermatomes they will be working in (no need to cover sacral roots). This is all assuming he isn't anticoagulated to the point of contraindicating a spinal. As an aside, I wonder if the cardiologist even puts one second of thought into anticoagulation when issuing the BS statement that they are cleared for spinal only. Maybe the cardiologist should place the spinal that he is clearing the patient for.


As for phenylephrine in a low EF patient after spinal. It's not exactly a bad idea if used judiciously. Most of the BP elevation after a dose of phenylephrine is from venoconstriction leading to increased preload for the LV. It isn't simply an arteriolar constrictor that increases SVR. If it was, you'd never use it because you'd always be reducing forward flow and perfusion. Watch what happens to cardiac output when you give it to someone with a PA catheter in place, the CO goes up along with the BP. Now when you get down to someone with a really crappy LV, you have to be careful because you are increasing the afterload to some extent, but the increase in preload will usually outweigh the elevated afterload when it comes to the cardiac output.



If I was doing this case it'd either be an isobaric spinal or under MAC with the surgeon infiltrating plenty of local. If I did GA, I'd want the surgeon to still use a decent amount of local so I could get by with minimal gas concentrations.

This is an aside--- All spinals will cover the sacral roots. SAB works at the spinal cord, not the nerve roots. You block everything below the highest extension of the level. What you say is correct if you are talking about an epidural.

 

[militarymd]

This is an aside--- All spinals will cover the sacral roots. SAB works at the spinal cord, not the nerve roots. You block everything below the highest extension of the level. What you say is correct if you are talking about an epidural.

I frequently do isobaric spinals. 0.5% bupivicaine 3 cc into CSF....and frequently, the ankles are NOT numb.

 

[Noyac]

I frequently do isobaric spinals. 0.5% bupivicaine 3 cc into CSF....and frequently, the ankles are NOT numb.

Exactly.

Intubate, the spinal cord may not be completely penetrated. The deep parts of the SC are the most distal regions of the body. This is why people get burned when they place a spinal for foot surgery and only give a small dose b/c they think the spinal works from the feet up. The dose is to small to completely penetrate the SC.

Ever seen a pt who could still wiggle their toes under a spinal during a c/s?

 

[urge]

Ever seen a pt who could still wiggle their toes under a spinal during a c/s?

Very often.

 

[dfk]

This is an aside--- All spinals will cover the sacral roots. SAB works at the spinal cord, not the nerve roots. You block everything below the highest extension of the level. What you say is correct if you are talking about an epidural.

barash p. 707 5th ed.--
"following intrathecal administration in animals local anesthetic is found in all sites between the spinal nerve rootlets and the inteior of the spinal cord. thus, neural blockade can potentially occur at any or all points along the neural pathways extnding from the site of drug administratio to the interior of the spinal cord."
"in an interesting study in humans...these investigators concluded that neural pathways within the spinal cord were largely intact during spinal anesthesia and that the spinal nerve rootlets were the principal site of neural blockade."

 

[powermd]

I would probably try to get away with ketofol and local first, and if that didn't work, an LMA.

Anyone concerned about the recovery from a spinal, when all that fluid you gave returns to the central vasculature? You would have to run this guy really dry with a lot of phenylephrine, and hope it works on his crappy atherosclerotic vessels. OTH, people with crappy atherosclerotic vessels tend not to drop their pressure that hard... but can still be very labile. Maybe a titrated epidural would be a safer way to go than spinal.

Isn't this guy on plavix or coumadin. I mean, c'mon, you don't get to an EF of 5-10% without some co-morbidities!

 

[Mman]

As mentioned above, with an isobaric spinal you will not see great coverage of sacral nerve roots. You also will not see much in the way of hemodynamic changes and consequently will not have to give much IVF to maintain blood pressure.

We do them frequently for sick old dudes and dudettes having hips fixed and it works quite nicely the vast majority of the time.

http://www.ncbi.nlm.nih.gov/pubmed/10410404

 

[SleepIsGood]

You guys keep saying things are different in PP but think about it. Do what is practical. Do what makes sense. I'm not telling you to do something risky or unsafe. I'm telling you how to do a case like this without getting into a big mess. One thing we do very well in anesthesia is manage risk. i believe we do this better than any other field of medicine out there. ****, it is the bread and butter of our career.
So stop telling me we do things differently in PP. Ask your attendings, WHY? don't just do what they tell you. Make sure it makes sense to you.

You are telling me you are afraid to put an LMA in someone like this b/c of laryngospasm? Give me a break. Laryngospasm is easy to fix, hypotension is someone with **** for cardiac fxn is not always easy to fix. I'll take laryngospasm any day. 20mg sux will fix it no problem and they don't need to be intubated. Full stomach, oh well. I guess if he ate a cheeseburger on the way to the OR I'd be worried.

Ask why, what we preach here is considered wrong by your attendings. If you feel we are leading you in the wrong direction, ask your attending (preferably one you respect). If the answer makes sense and you believe it is better than what I or some of our PP crew here states then fine, go with it.

PS: you will see the light soon enough.

Hey Noy

No worries..I hear you. The thing is as a resident, we generally cant do something that the attending doesnt want. We can mk an argument one way or another. If theyre set on their way...that's it.. It's their license after all. That's why I differentiate the PP way vs residency.

 

[Planktonmd]

Anyone concerned about the recovery from a spinal, when all that fluid you gave returns to the central vasculature?

Why do you have to give a lot of fluids??

 

[urge]

Why do you have to give a lot of fluids??

Because titrating drips in pts with such poor EF takes a Looooooonnnngggg time. It will no be perfect from the get go. So, you will bolus and rebolus and then bolus some more. That's my humble opinion. Doesn't mean it cannot be done. Just a PITA.

 

[Planktonmd]

Because titrating drips in pts with such poor EF takes a Looooooonnnngggg time. It will no be perfect from the get go. So, you will bolus and rebolus and then bolus some more. That's my humble opinion. Doesn't mean it cannot be done. Just a PITA.

Are you saying that giving a volume load can improve hemodynamics faster in this patient than giving a pressor?
If you don't cause hypotension to start with you will not need to fix it.

 

[urge]

Are you saying that giving a volume load can improve hemodynamics faster in this patient than giving a pressor?

No. I'm saying you will have to flush your multiple boluses. It will add up to quite a bit of volume in this pt. Volume could be detrimental in this pt.

How come nobody has mentioned a illioinguional block? Sounds good in this scenario. I have never done one, though.

 

[Arch Guillotti]

Analgesic based sedation with remi and a touch (25mcg/kg/min) propofol seems to do wonders with these gomers even for high stimulation cases.
Call me a woos but i wouldnt burn my bridges with a spinal then chase it with epi..just not worth it in my opinion.

Ive been trying remi alot lately and its great for stable hemodynamics and "stuns" the patient fast like ketamine without the hypertension and tachycardia

How much remi are you running on these pts? When do you seem to see resp. depression? I used it mostly for neuro cases during residency. Also did a couple of inductions with it. Never really used it for sedations though.

 

[Intubate]

Sorry for my previous ******ed post.

Of course subarachnoid local anesthetics work at the nerve roots (possibly the cord too, apparently). This is why we sit people up for saddle blocks or turn them lateral to block one side. Also obvious is the fact that lower roots are sometimes spared (ie the intact L5 in a CS patient), particularly with isobaric local.

What I was trying to point out (albeit extremely poorly and with obviously incorrect information) is that you are likely "covering" the roots somewhat because you are basically injecting your dose all over them when you get in the CSF in the lumbar region (below the cord in the cauda equina). You expose all roots at and below and several (or more) above the level at which you inject. The reason for the difference in blockade isn't totally clear I dont think, but the lower roots seem to take more "soaking".

With an epidural of course, you only block the nerve roots as they exit the spine and the dural sheath thins, so you get a pure segmental block. This was my point. Again, poorly explained, badly mistimed, and generally incorrect the first time around.

Another thing to point out is that the site of action of epidural/subarachnoid opioids is for the most part in the spinal cord itself (for real this time), and interestingly gives segmental analgesia. This is useful when treating a parturient with a lumbar catheter that is giving poor sacral root coverage that you want comfortable but without total motor block. A dose of opioids at the high lumbar area delivers the drug to the "sacral level" of the cord.

Again, I apologize for before, and thanks for berating me appropriately.

 

[Arch Guillotti]

I frequently do isobaric spinals. 0.5% bupivicaine 3 cc into CSF....and frequently, the ankles are NOT numb.

Hmm, interesting. I routinely used .5% bupi for ankles in residency and never heard any problems w/incomplete blocks. Of course I just placed the block and the NURSE sat the case🙄. Also would frequently place sciatic block or subgluteal cath as well. And a general if they were prone.

 

[apma77]

for sedation i run remi at 0.0375-0.1 mcg/kg/min after dosing with bolus of 1mcg/kg over 5 min..DO NOT quick bolus remi unless you want to see hypotension, stiff chest or bradycardia.

awesome drug for analgesic based sedation!

 

[jetproppilot]

Pt came in with inguinal hematoma (urgent case), EF 5-10% non ischemic cardiomypoathy; bullshi# cardiology "clearance" indicates "pt cleared for spinal only"
what a BS setup!!
i call the cardiologist prior to proceeding ; NO answer after multiple pages
also in cardiac eval says "pt needs AICD evaluation soon"

now why the hell would i do a spinal , give sympathectomy possibly and burn my bridges???
putting this guy under GA is also dangerous...

so what did i do?? I did it under MAC with 2 mg versed and REMIfentanil infusion. no problems...pt did well.. i couldnt believe i got away with it...

anyone here would do a spinal on this guy?? (maybe an epidural but a spinal??)

Don't know the right answer to this clinical question since there isnt a "right" answer but I'll quote Military MD:

".....only ANESTHESIOLOGISTS clear patients for surgery.....👍

I need to get on WIKIPEDIA and post that

"THERES NO SUCH THING AS BEING CLEARED FOR SPINAL ANESTHESIA ONLY, DICKHOLE."

 

[Planktonmd]

Don't know the right answer to this clinical question since there isnt a "right" answer but I'll quote Military MD:

".....only ANESTHESIOLOGISTS clear patients for surgery.....👍

I need to get on WIKIPEDIA and post that

"THERES NO SUCH THING AS BEING CLEARED FOR SPINAL ANESTHESIA ONLY, DICKHOLE."

😍

 

[Arch Guillotti]

"THERES NO SUCH THING AS BEING CLEARED FOR SPINAL ANESTHESIA ONLY, DICKHOLE."

I about spit out my pepsi as I read this. I am thinking about putting this line as my sig. This is too funny. I don't think it would fly too well outside this forum though.